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Health Data Managementand Health ServicesOrganization and Delivery
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CHAPTER
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1. Definition, Purpose, Uses, and Users of the Health Recorda. Health Record Defined
i. Also referred to as the medical record, patient record, residentrecord, or client record
ii. Identifies the patient, the diagnosis, treatments rendered, anddocumentation of all results
iii. Used as a documentation tool for continuous patient careiv. Serves as a communication tool for health care professionalsv. Serves as a data and information collection tool for all health care
servicesvi. Combination of discrete data elements and narrative in various
media, including paper, electronic, voice, images, and waveformsvii. Electronic health record
1. Health care information managed by electronic system(s) used tocapture, transmit, receive, store, retrieve, link, and manipulatemultimedia data
b. Purpose of Health Recordi. Primary source of health data and information for the health care
industryii. Created as a direct byproduct of health care delivered in a health
setting and is the legal documentation of care provided by the healthcare professionals
iii. A valuable source of aggregate data for research and programevaluation
iv. Health care reimbursementc. Uses of Patient Record
i. Documenting health care services provided to an individual in orderto support ongoing communication and decision making amonghealth care providers1. Planning and managing diagnostic, therapeutic, and nursing services
ii. Establishing a record of health care services provided to anindividual that can be used as evidence in legal proceedings1. Protects the legal interest of the patient, health care provider, and
health care organization
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iii. Assessing the efficiency and effectiveness of the health care servicesprovided1. Evaluating the adequacy and appropriateness of care
iv. Documenting health care services provided in order to supportreimbursement claims that are submitted to payers
v. Supplying data and information that support the strategic planning,administrative decision making, and research activities as well assupport the public policy development related to health care(regulations, legislation, and accreditation standards)
d. Five Unique Roles of a Patients Health Recordi. A record of the patients health status and the health services
provided over timeii. Provides a method for clinical communication and care planning
among the individual health care practitioners serving the patientiii. Serves as the legal document describing the health care services
providediv. A source of data for clinical, health services, and outcomes researchv. Serves as a major resource for health care practitioner education
e. Users of Patient Record and Health Datai. Patient
ii. Health care practitionersiii. Health care providers and administratorsiv. Third-party payersv. Utilization managers
vi. Quality of care committeesvii. Accrediting, licensing, and certifying agencies
viii. Governmental agenciesix. Attorneys and the courts in the judicial processx. Planners and policy developers
xi. Educators and trainersxii. Researchers and epidemiologists
xiii. Media reporters2. Format of the Health Record
a. Source-Oriented Health Recordi. Documents are organized into sections according to the practitioners
and departments that provide treatment.1. Example
a. Laboratory records are grouped together, radiology records aregrouped together, clinical notes are grouped together, and so on.
b. Problem-Oriented Health Recordi. Developed by Dr. Lawrence Weed in the 1960s, in response to the
lack of clarity of the patients problems in the source-oriented recordii. Divided into four parts
1. Database2. Problem list3. Initial plan4. Progress notes (SOAP)
a. Subjectivei. Patient states the problem to health care provider.
b. Objectivei. What the practitioner identifies
c. Assessmenti. Combines the subjective and objective to make a
conclusion
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d. Plani. The approach to be taken to resolve the patients problem
c. Integrated Health Recordsi. Documentation from various sources is intermingled and organized
in strict chronological or reverse chronological order.ii. Advantage is that it is easy to follow the course of the patients
diagnosis and treatment.iii. Disadvantage is that the format makes it difficult to compare similar
information.3. Basic Principles of Health Record Documentation
a. General Documentation Guidelines of the American Health InformationManagement Association (AHIMA)
i. Uniformity of both the content and format of the health recordii. Organized systematically to facilitate data retrieval and compilation
iii. Only authorized individuals should be allowed to document in therecord.
iv. Policies must identify which individuals may receive and transcribeverbal physicians orders.
v. Documentation should occur when the services were rendered.vi. Entries should identify authors clearly.
vii. Individuals making entries should use only abbreviations andsymbols approved by the organization and/or medical staff.
viii. All entries in the record should be permanent.ix. Error correction for paper-based records
1. Never obliterate errors; original entry should remain legible, andcorrections should be entered in chronological order.
2. Draw a single line in ink through the incorrect entry. Print erroror correction at the top of the entry along with a legal signatureor initials, date, time, reason for change, and the title anddiscipline of the individual making the correction. Add correctinformation to the entry.
3. Late entries should be labeled as such.x. Any corrections on information added to the record by the health
care provider from verbal corrections from the patient should beinserted as an addendum or a separate note with no changes in theoriginal entries in record.
xi. Health information department should develop, implement, andevaluate policies and procedures related to the quantitative andqualitative analysis of the health record.
b. Common Time Frames for Completion of Health Record Documentsi. History and physical: within 24 hours of admission
ii. Operative report: immediately following surgeryiii. Verbal orders: cosigned within 24 hoursiv. Discharge summary: immediately after discharge of patient
c. The Joint Commission (TJC, formerly the Joint Commission onAccreditation of Healthcare Organizations, or JCAHO) Type IRecommendation
i. Too many delinquent records may cause the hospital to receive aType I Recommendation, which must be resolved in order to retainaccreditation.
ii. Guidelines that indicate a Type I Recommendation1. The number of delinquent records is greater than 50% of the
average number of discharged patients per quarter, over theprevious 12 months.
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2. All medical records must have a history documented within 24hours.
3. All medical records, including a surgery, must have an immediatepostoperative note documented, and the operative report must bedictated immediately after surgery.
4. Content of the Acute Care Health Recorda. Administrative Data (includes demographic and financial information as
well as various consent and authorization forms related to the provision ofcare and the handling of confidential patient information)
i. Registration recordii. Consent to treatment
iii. Consent to release informationiv. Consent to special proceduresv. Advanced directives
vi. Patient rights acknowledgmentvii. Property and valuables list
viii. Birth and death certificatesb. Clinical Data (documents the patients medical condition, diagnosis, and
treatment as well as the health care services provided)i. Medical history and review of systems
ii. Physical examinationiii. Interdisciplinary patient care planiv. Physicians ordersv. Progress notes (clinical observations)
vi. Reports and results of diagnostic and therapeutic proceduresvii. Consultation reports
viii. Discharge and interval summary that includes final instructions givento patient upon discharge
ix. Operative data1. Anesthesia report2. Recovery room record3. Operative report4. Pathology report
x. Obstetric data1. Antepartum record2. Labor and delivery record3. Postpartum record
xi. Neonatal data1. Birth history2. Neonatal identification3. Neonatal physical examination4. Neonate progress notes
xii. Nursing data1. Nursing notes2. Graphic sheet3. Medication sheet4. Special care units
xiii. Ancillary data1. Electrocardiographic reports2. Laboratory reports3. Radiology and imaging reports4. Radiation therapy5. Therapeutic services
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6. Case management and social service record7. Patient and family teaching and participation8. Discharge and follow-up plan
5. Record Content for Alternative Health Care Sitesa. Ambulat